questions for neuro
The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?
"Have you experienced any viral infections in the last month?" An antecedent event (most often a viral infection) precipitates clinical presentation. The antecedent event usually occurs about 2 weeks before the symptoms begin. Ptosis is a common symptom associated with myasthenia gravis. Urination and development of allergies are not associated with Guillain-Barre.
Which are risk factors for spinal cord injury (SCI)? Select all that apply. 1- Young age 2- Female gender 3- Alcohol use 4- Drug abuse 5- Caucasian ethnicity
1,3,4
The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?
Diplopia and ptosis The initial manifestation of myasthenia gravis involves the ocular muscles, such as diplopia and ptosis. The remaining choices relate to multiple sclerosis.
Which of the following is the initial diagnostic test for a stroke?
Noncontrast CT scan.
A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of:
Parkinson's disease Although antiparkinson drugs are used in some clients with Huntington's disease, these drugs are most commonly used in the medical management of Parkinson's disease. The listed medications are not used to treat a seizure disorder. The listed medications are not used to treat MS.
*A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do?
Provide close supervision because of the client's impulsiveness and poor judgment.
A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:
Severe TBI. A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.
Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke.
The physician may use dexamethasone to decrease cerebral edema and pressure;
A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase?
preventing further neurologic damage The focus of management during the acute phase is to stabilize the client and prevent further neurologic damage.
Which of the following are the most commonly reported clinical manifestations of multiple sclerosis? Select all that apply. a) Aphasia b) Numbness c) Fatigue d) Spasticity e) Depression f) Pain
• Numbness• Pain• Spasticity• Fatigue• Depression
The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? 1- Hypophysectomy 2- Application of Halo traction 3- Burr holes 4- Insertion of Crutchfield tongs
3
Which medication classification is used preoperatively to decrease the risk of postoperative seizures?
Anticonvulsants Anticonvulsants are used to decrease the risk of postoperative seizures following cranial surgery. Diuretics, corticosteroids, and antianxiety medications may be used for the client with increased intracranial pressure
Which is often the most disabling clinical manifestation of multiple sclerosis (MS)? A. Pain B. Fatigue C. Spasticity D. Ataxia
B
The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following?
Bacteria Septic meningitis is caused by bacteria. In aseptic meningitis, the cause is viral or secondary to lymphoma, leukemia, or human immunodeficiency virus.
Which is the most common cause of spinal cord injury (SCI)?
Motor vehicle crashes The most common cause of SCI is motor vehicles crashes, which account for 35% of the injuries. Falls, sports-related injuries, and acts of violence are also potential causes of SCI, but are not most common.
Which of the following is the initial diagnostic in suspected stroke?
Noncontrast computed tomography (CT) An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.
Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury?
Placing a blanket over the client An object on the skin or skin pressure may precipitate an autonomic dysreflexic episode. In general, constipation or fecal impaction triggers autonomic dysreflexia. When the client is observed to be demonstrating signs of autonomic dysreflexia, the nurse immediately places the client in a sitting position to lower blood pressure. The most common cause of autonomic dysreflexia is a distended bladder.
After a seizure, the nurse should place the patient in which of the following positions to prevent complications?
Side-lying, to facilitate drainage of oral secretions To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.
The diagnosis of multiple sclerosis is based on which test? 1- CSF electrophoresis 2- Magnetic resonance imaging 3- Evoked potential studies 4- Neuropsychological testing
2
A client with meningitis has a history of seizures. Which of the following should the nurse do to safely manage the client during a seizure? Select all that apply. A. Turn Pt to the side B. Physically Restrain Pt's Movements C. Inspect Oral Cavity D. Provide Verbal Reassurance
A, D
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?
Increased pulse rate, adventitious breath sounds An increased pulse rate above baseline with adventitious breath sounds indicate compromised respirations and signal a need for airway clearance. A decrease in pulse rate is not indicative of airway obstruction. An increase of pulse rate with slight elevation of respirations (16 breaths/minute) is not significant for suctioning unless findings suggest otherwise.
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord?
Multiple sclerosis The cause of MS is not known, and the disease affects twice as many women as men. Parkinson disease is associated with decreased levels of dopamine caused by destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia. Creutzfeldt-Jakob disease is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain.
A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate?
Notify the physician of a possible cerebrospinal fluid leak. Any sudden discharge of fluid from a cranial incision is reported at once, because a large leak requires surgical repair. Attention should be paid to the patient who complains of a salty taste or "postnasal drip," because this can be caused by cerebrospinal fluid trickling down the throat.
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? 1- Akathisia 2- Spasticity 3- Ataxia 4- Myoclonus
2
Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition? 1- Examine the skin for any area of pressure or irritation. 2- Examine the rectum for a fecal mass. 3- Empty the bladder immediately. 4- Raise the head of the bed and place the patient in a sitting position.
4
The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? 1- Occipital skull fracture 2- Temporal skull fracture 3- Frontal skull fracture 4- Basilar skull fracture
4
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator aka tPA?
Every 15 minutes and vital signs except temperature should be taken every 15 minutes while receiving tPA infusion.
Which of the following is considered a central nervous system (CNS) disorder?
Multiple sclerosis Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the CNS. Guillain-Barré, myasthenia gravis, and Bell's palsy are peripheral nervous system disorders.
A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide?
"You must avoid stress and extreme fatigue, because these can trigger a relapse." Stress, fatigue, and temperature extremes can trigger relapses of MS. The client should be taught to practice a healthy lifestyle, including good nutrition, adequate sleep, and management of stress. Clients taking MS medications should take them on a consistent and strict schedule to produce the desired effect of fewer relapses and to prevent sclerotic plaque from forming on the brain and spinal cord. RRMS is characterized by states of remission and relapses. A steady decline in function is consistent with primary progressive MS. RRMS is the most common type, and many treatments are available.
A client with a traumatic brain injury has developed increased intracranial pressure resulting in dibetes insipidus. While assessing the client, the nurse expects which of the following findings? 1- Excessive urine output and decreased urine osmolality 2- Oliguria and decreased urine osmolality 3- Oliguria and serum hyperosmolarity 4- Excessive urine output and serum hypo-osmolarity
1
A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? 1- Monro-Kellie 2- Cushing's 3- Dawn phenomenon 4- Hashimoto's disease
1
The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following? 1- Approximately 60% to 75% of clients recover completely. 2- Only a very small percentage (5% to 8%) of clients recover completely. 3- Usually 100% of clients recover completely. 4- No one with Guillain-Barre syndrome recovers completely.
1
A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago. What medication does the nurse know will be given to prevent further spinal cord damage? 1- Furosemide (Lasix) 2- Methylprednisolone (Solu-Medrol) 3- Cyclobenzaprine (Flexeril) 4- Hydralazine hydrochloride (Apresoline)
2
A patient who has sustained a basal skull fracture is admitted to the neurological unit. The nurse should know that the patient should be observed for: 1- An area of bruising over the mastoid bone 2- Bleeding from the ears 3- An increase in pulse 4- Difficulty sleeping
2
Episodes of orthostatic hypotension occur in the first 2 weeks after a spinal cord injury. Compare the two blood pressure measurement for each answer. The blood pressure reading obtained when the patient was sitting, is in the left column for comparison. Which of the following shows the blood pressure measurement indicative of orthostatic hypotension? 1- 140/110 130/110 2- 140/100 120/90 3- 130/90 125/85 4- 130/80 120/80
2
The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)? 1- Position the client in the supine position 2- Maintain cerebral perfusion pressure from 50 to 70 mm Hg 3- Restrain the client, as indicated 4- Administer enemas, as needed
2
A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? 1- Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction 2- Ineffective cerebral tissue perfusion related to increased intracranial pressure 3- Disturbed thought processes related to brain injury 4- Ineffective airway clearance related to brain injury
4
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? 1- Encouraging oral fluid intake 2- Suctioning the client once each shift 3- Elevating the head of the bed 90 degrees 4- Administering a stool softener as ordered
4
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? 1- A bounding pulse 2- Bradycardia 3- Hypertension 4- Lethargy and stupor
4
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? 1- Extreme thirst 2- Intake and output 3- Nutritional status 4- Body temperature
4
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
Absence of reflexes along with flaccid extremities During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.
Myasthenia gravis occurs when antibodies attack which receptor sites?
Acetylcholine In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction. Serotonin, dopamine, and gamma-aminobutyric acid are not receptor sites that are attacked in myasthenia gravis.
A client is suspected to have bacterial meningitis. What is the priority nursing intervention?
Administer prescribed antibiotics. A client with suspected bacterial meningitis should receive antibiotic therapy within 30 minutes of arrival. Outcomes are usually better with early administration of antibiotics. Although the nurse should assess the CSF laboratory test results, antibiotic therapy should not be delayed waiting for the results. Encouraging oral fluids and preparing for a CT scan are appropriate interventions depending on the client, but the priority intervention is the early administration of antibiotics.
A college student goes to the infirmary with a fever, headache, and a stiff neck. The nurse suspects the student may have meningitis and has the student transferred to the hospital. If the diagnosis is confirmed, what should the nurse institute for those who have been in contact with this student? Select all that apply.
Administration of rifampin (Rifadin) Administration of ciprofloxacin hydrochloride (Cipro) Administration of ceftriaxone sodium (Rocephin) People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin).
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?
Alternatively patch one eye every 2 hours. Patching one eye at a time relieves diplopia (double vision). Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat diplopia.
A client with a spinal cord injury has full head and neck control when the injury is at which level? 1- C1 2- C2 to C3 3- C4 4- C5
4
The most common cause of cholinergic crisis includes which of the following?
Overmedication A cholinergic crisis, which is essentially a problem of overmedication, results in severe generalized muscle weakness, respiratory impairment, and excessive pulmonary secretion that may result in respiratory failure. Myasthenic crisis is a sudden, temporary exacerbation of MG symptoms. A common precipitating event for myasthenic crisis is infection. It can result from undermedication.
The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for
renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. To prevent relapse, treatment with acyclovir should continue for up to 3 weeks.
Which Nursing Diagnosis takes the highest priority for a client w/ Parkinson's Disease? A. Imbalanced Nutrition B. Ineffective Airway Clearance C. Impaired Urinary Elimination D. Risk for Injury
B
A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside? A. Sphygmomanometer B. Padded Tongue Blade C. Nasal Cannula + Oxygen D. Suction Machine w/ Catheter
D
A nurse is assessing a client with Parkinson's Disease. Which of the following would the nurse expect to find? A. Gait w/ the Body Leaning Backwards B. Continuous Tremors C. Muscle Flaccidity D. Slowing of Activity
D
The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education?
"I will stretch daily as directed by the physical therapist." A stretching routine should be established. Stretching can help prevent contractures and muscle spasticity. Hot baths are discouraged because of the risk of injury. Clients have sensory loss that may contribute to the risk of burns. In addition, hot temperatures may cause an increase in symptoms. Warm packs should be encouraged to provide relief. Progressive weight-bearing exercises are effective in managing muscle spasms. Clients should not hurry through the exercise activity because it may increase muscle spasticity.
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
"The paralysis caused by this disease is temporary." The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs
The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse?
"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." The survival rate of Guillain-Barré syndrome is approximately 90%. The client may make a full recovery or suffer from some residual deficits. Telling the parents not to worry dismisses their feelings and does not address their concerns. Progression of Guillain-Barré syndrome to the diaphragm does not significantly decrease the survival rate, but it does increase the chance of residual deficits. The family should be given information about Guillain-Barré syndrome and the generally favorable prognosis. With no prognosis offered, the parents are not having their concerns addressed.
A 36-year-old male patient is preparing for discharge from the hospital to a rehabilitative facility 4 weeks after he suffered a spinal cord injury (SCI) during a workplace accident. The hospital nurse should be aware that the primary focus of this coming phase of the patient's recovery will be: 1- Providing him with the skills to perform as many activities of daily living (ADLs) as possible 2- Ensuring that he adheres to the prescribed treatment regimen before being discharged home 3- Helping him establish therapeutic relationships with people who have had similar injuries 4- Allowing him to receive care in a setting that is less institutional than a hospital
1
A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? 1- Take daily weights. 2- Reposition the client frequently. 3- Assess for pupillary response frequently. 4- Assess vital signs frequently.
1
A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: 1- shivering in hypothermia can increase ICP. 2- hypothermia is indicative of severe meningitis. 3- hypothermia is indicative of malaria. 4- hypothermia can cause death to the client.
1
A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for? 1- Rebound hypotension 2- Rebound hypertension 3- Urinary tract infection 4- Spinal shock
1
A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? 1- Decerebrate posturing and loss of corneal reflex 2- Loss of gag reflex and mental confusion 3- Complaints of headache and lack of pupillary response 4- Mental confusion and pupillary changes
1
The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures? 1- Insertion of a nasogastric tube 2- A large volume enema 3- Digital stimulation 4- Bowel surgery
1
The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? 1- Insertion of a nasogastric (NG) tube 2- Urine testing for acetone 3- Serum sodium concentration testing 4- Out of bed to the chair three times a day
1
The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern? 1- Temperature increase from 98.0°F to 99.6°F 2- Urinary output increase from 40 to 55 mL/hr 3- Heart rate decrease from 100 to 90 bpm 4- Pulse oximetry decrease from 99% to 97% room air
1
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? 1- Check the equipment. 2- Contact the physician to review the care plan. 3- Continue the assessment because no actions are indicated at this time. 4- Document the reading because it reflects that the treatment has been effective.
1
Which are characteristics of autonomic dysreflexia? 1- severe hypertension, slow heart rate, pounding headache, sweating 2- severe hypotension, tachycardia, nausea, flushed skin 3- severe hypertension, tachycardia, blurred vision, dry skin 4- severe hypotension, slow heart rate, anxiety, dry skin
1
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply. 1- Bradycardia 2- Bradypnea 3- Hypertension 4- Tachycardia
1,2,3
At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply. 1- Bradycardia 2- Hypertension 3- Bradypnea 4- Hypotension 5- Tachycardia
1,2,3
Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply. 1- Decreased glucose 2- Increased protein 3- Increased white blood cells 4- Decreased protein 5- Increased glucose
1,2,3
A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following? 1- Fluid restriction 2- Vasopressin therapy 3- Hypertonic saline solution 4- Diet containing extra sodium
2
Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers? 1- Continuous use of an indwelling catheter 2- Meticulous cleanliness 3- Avoidance of all lotions and lubricants 4- Allowing the client to choose the position of comfort
2
The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration? 1- Extradural hematoma 2- Epidural hematoma 3- Subdural hematoma 4- Intracranial hematoma
2
The staff educator is orientating a nurse new to the neurological ICU when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. What sign or symptom is consistent with this diagnosis? 1- Increased cardiac biomarkers 2- Hypotension 3- Tachycardia 4- Excessive sweating
2
A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? 1- Maintaining adequate hydration 2- Administering prescribed antipyretics 3- Restricting fluid intake and hydration 4- Hyperoxygenation before and after tracheal suctioning
3
The emergency department nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. The patient is exhibiting an altered level of consciousness. Following a skull X-ray, the patient is diagnosed with a basilar skull fracture. Which sign should alert the nurse to this type of fracture? 1- Babinski sign 2- Kernig's sign 3- Battle's sign 4- Brudzinski's sign
3
The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction? 1- "I will change the vest liner periodically." 2- "If a pin becomes detached, I'll notify the surgeon." 3- "I can apply powder under the liner to help with sweating." 4- "I'll check under the liner for blisters and redness."
3
Which Glasgow Coma Scale score is indicative of a severe head injury?
7 A score between 3 and 8 is generally accepted as indicating a severe head injury.
A new ancillary staff member is assisting the nurse with a client diagnosed with Parkinson's disease. The client needs assistance with eating but doesn't require thickened liquids to aid swallowing. Which instruction should the nurse give the ancillary staff member about eating assistance? A. Make sure the client is sitting w/ the head of bed elevated to 90 degrees B. Assist the client into a comfortable position and stay alert for coughing, which signifies aspiration C. Clients with Parkinson's Disease shouldn't have liquids; remove them from the dinner tray before serving the food to the pt D. There are no special precautions for the client w/ Parkinson's Disease
A
A patient diagnosed with multiple sclerosis (MS) has ataxia. Which of the following medications could be used to treat this clinical manifestation? A. Neurontin B. Baclofen C. Valium D. Dantrium
A
The earliest sign of serious impairment of brain circulation related to increased ICP is:
A change in consciousness. The earliest sign of increasing ICP is a change in the LOC. Any changes in LOC should be reported immediately.
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?
A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self" Autoimmune disorders are those in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self." Autoantibodies, antibodies against self-antigens, are immunoglobulins. They target histocompatible cells, cells whose antigens match the person's own genetic code. Autoimmune disorders are not caused by too many or too few immunoglobulins, and histocompatible cells do not attack immunoglobulins in an autoimmune disorder.
A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapherisis and explains this in which of the following statements?
Antibodies are removed from the plasma. Plasmapheresis is a technique in which antibodies are removed from plasma and the plasma is returned to the client. The other three choices are appropriate treatments for myasthenia gravis, but are not related to plasmapheresis.
Which nursing intervention is appropriate for a client with double vision in the right eye due to MS?
Apply an eye patch to the right eye. An eye patch to the affected eye would help the client with double vision see more clearly, thus promoting safety. Exercises for the eye would not benefit the client. Eye drops may be needed for dryness to prevent corneal abrasion but would not have any benefit for a client with double vision. Needed items should be placed on the unaffected (left) side.
If warfarin is contraindicated as a treatment for stroke, which of the following medication is the best option?
Aspirin
Which nursing intervention is the priority for a client in myasthenic crisis?
Assessing respiratory effort A client in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early. Administering IVIG, preparing for plasmaphersis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.
Which of the following, if left untreated, can lead to an ischemic stroke?
Atrial fibrillation Atrial fibrillation if left untreated, it can lead to an ischemic stroke.
You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?
Autonomic dysreflexia Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?
Avoid hot baths and showers." The nurse should instruct a client with MS to avoid hot baths and showers because they may exacerbate the disease. The nurse should encourage daytime naps because fatigue is a common symptom of MS. A client with MS doesn't require food or fluid restrictions.
A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include?
Avoid hot temperatures. Fatigue affects most people with MS. Avoidance of hot temperatures may help control fatigue. A balance of rest and activity is a good strategy, but avoidance of any physical activity is not recommended. Avoidance of all alcohol is a good strategy. Analgesics may be required for pain management.
Which positions is used to help reduce intracranial pressure (ICP)?
Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.
During assessment of a patient who has been taking Dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect? A. Alopecia B. Gingival Hyperplasia C. Diplopia D. Ataxia
B
A patient has just been diagnosed with Parkinson's disease. The nurse is teaching the patient and his family about dietary practices related to Parkinson's disease. Which of the following are risks for this client? Select all that apply. A. Fluid overload B. Dysphagia C. Choking D. Constipation. E. Anorexia
B, C, D
A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?
Basilar Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).
The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?
Basilar skull fracture A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.
Which of the following is the most common side effect of tissue plasminogen activator tPA?
Bleeding. Patient is closely monitored for bleeding at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness.
At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.
Bradycardia Hypertension Bradypnea The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated immediately.
The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?
Burr holes An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.
The nurse is advising a client with multiple sclerosis on methods to minimize spasticity and contractures. Which of the following techniques would the nurse instruct the client to perform? A. Avoid swimming and any weight-bearing activity. B. Exercise following a circuit training regimen. C. Apply warm packs to the affected area. D. Relax in a hot bath.
C
When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred?
C5 The nurse should anticipate that the injury has occurred at level C5. Injuries above C3 result in the loss of spontaneous respiratory function. Clients with injuries at T6 and L1 retain some degree of upper limb use and sensation.
Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following is cause of a secondary injury associated with brain injury? Select all that apply.
Cerebral edema Ischemia Infection Seizures Hyperthermia Secondary injury evolves over the ensuing hours and days after the initial injury and can be due to cerebral edema, ischemia, seizures, infection, hyperthermia, hypovolemia, and hypoxia.
Regarding a transient ischemic attack, lifestyle changes would include Blood pressure control. Weight loss. Antiplatelet therapy.
Controlling hypertension, losing weight, and anticoagulant/antiplatelet therapy are typical medical interventions prescribed to prevent stroke.
A client who is at high-risk for a cerebrovascular accident has medication ordered to lower their cholesterol and to prophylactically anticoagulate them. What specific agent might be diagnosed for this client?
Daily aspirin . Specific agents include daily aspirin as well as antiplatelet or anticoagulant therapy such as clopidogrel aka Plavix), ticlopidine aka Ticlid), warfarin aka Coumadin, and dipyridamole aka Persantine. Heparin is not the drug of choice for prophylactic anticoagulation therapy.
Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply.
Decreased glucose Increased protein Increased white blood cells CSF studies demonstrate decreased glucose, increased protein levels, and increased white blood cells.
The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?
Drooping eyelids Ptosis (eyelid drooping) is the most common manifestation of myasthenia gravis. Muscle weakness varies depending on the muscles affected. Shortness of breath and respiratory distress occurs later as the disease progresses. Muscle spasms are more likely in multiple sclerosis. Photophobia is not significant in myasthenia gravis.
The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate?
Edema to the head with bruising of the mastoid process Battle's sign is the presence of bruising of the mastoid process behind the ear. It is not related to periorbital bleeding, lacerations, or fixed pupils.
A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease?
Elevated protein levels in the CSF Serum laboratory tests are not useful in the diagnosis. However, elevated protein levels are detected in CSF evaluation, without an increase in other cells.
The nurse is caring for a client who has had a cerebrovascular accident. The client has difficulty swallowing. What intervention would it be important for the nurse to institute?
Encourage client to eat semisolid foods and cold foods. Semisolid and medium-consistency foods such as pudding, scrambled eggs, cooked cereals, and thickened liquids are easiest to swallow. Cold foods stimulate swallowing. Avoid tepid foods as they are more difficult to locate in the mouth.
The nurse is expecting to admit a client with a diagnosis of meningitis. While preparing the client's room, which of the following would the nurse most likely have available?
Equipment to maintain infection control precautions An important component of nursing care for the client with meningits is instituting infection control precautions until 24 hours after initiation of antibiotic therapy. Oral and nasal discharge is considered infectious. This client may well experience photophobia, so the lighting should be kept dim. IV Tensilon is used to diagnose myasthenia gravis.
A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate?
Establishing an intermittent catheterization routine every 4 hours The paraplegic client with an L1-L2 injury will demonstrate flaccid paralysis. Developing an intermittent catheterization routine offers a way of manually draining the bladder, eliminating the need for an indwelling urinary catheter. With an injury at L1-L2, ambulation may be possible with long leg braces but not with short leg braces. Spasticity and autonomic dysreflexia are seen in clients with upper motor injuries above T6, not L1-L2 injuries.
While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe?
Facial pain in the areas of the fifth cranial nerve Tic douloureux (trigeminal neuralgia) is manifested by pain in the areas of the fifth (trigeminal) cranial nerve. Ptosis and diplopia are associated with myasthenia gravis. Hyporeflexia and weakness of the lower extremities are associated with Guillain-Barre syndrome. Fatigue and depression are associated with multiple sclerosis.
A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse?
Frequent neurologic checks If the client undergoes carotid artery surgery, the nurse performs frequent neurologic checks to detect paralysis, confusion, facial asymmetry, or aphasia.
A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intraveneously. The nurse is careful to assess which of the following related to intake of nutrients?
Gag reflex and bowel sounds Paralytic ileus may result from insufficient parasympathetic activity. The nurse may administer parenteral nutrition and IV fluids. The nurse carefully assesses for the return of the gag reflex and bowel sounds before resuming oral nurition. The other three choices are important assessment items, but not necessarily related to the intake of nutrients.
A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?
Generalized A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor.
The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?
Headache and nuchal rigidity Headache and fever are the initial symptoms of meningitis. Nuchal rigidity can be an early sign. Photophobia is also a well-recognized sign in meningitis. Ptosis and diplopia are usually seen with myasthenia gravis. Hyporeflexia in the legs is seen with Guillain-Barre syndrome.
A critical care nurse is caring for a client with a cerebrovascular accident (CVA) The client is prescribed heparin for treatment. The nurse knows to monitor the client for what adverse effects?
Hemorrhage. A client with a CVA who is given heparin should be monitored for hemorrhage and bleeding at the subcutaneous injection site.
Which is the most common cause of acute encephalitis in the United States?
Herpes simplex virus (HSV) HSV-1 ( herpes simplex virus) is the most common cause of acute encephalitis in the United States. Fungal infections of the central nervous system occur rarely in healthy people. The Western equine encephalitis virus is one of four types of arboviral encephalitis that occur in North America is one of several fungi that may cause fungal encephalitis. Lyme disease leads to flu like symptoms and starts as a local infection which can systematically spread causing organ issues, however the incidence is rate, HIV leads to autoimmune disorders.
When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?
Increased intracranial pressure (ICP) When ICP increases, Cushing triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?
Ineffective breathing pattern Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Impaired physical mobility, Disturbed sensory perception (tactile), and Dressing or grooming self-care deficit may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern.
A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first?
Initiate isolation precautions. The signs and symptoms are consistent with bacterial meningitis. The nurse should protect self, other health care workers, and other clients against the spread of the bacteria. Clients should receive the prescribed antibiotics within 30 minutes of arrival, but the nurse can administer the antibiotics after applying the isolation precautions. The nurse can use a cooling blanket to help with the elevated temperature, but this should be done after applying isolation precautions. Prophylaxis antibiotic therapy should be given to people who were in close contact with the patient, but this is not the highest priority nursing intervention.
The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?
Insertion of a nasogastric (NG) tube Clients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the client is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal feeding tube should be considered. If cerebrospinal fluid rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the client out of bed to a chair three times daily.
You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has?
Ischemic. Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain about 80% of strokes are the ischemic variety.
A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?
It allows for stabilization of the cervical spine along with early ambulation. Halo devices provide immobilization of the cervical spine while allowing early ambulation.
The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury?
It results from initial damage to the brain from the traumatic event. The primary injury results from the initial damage from the traumatic event. The secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually due to cerebral edema and increased intracranial pressure.
A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?
Keep the client's neck in a neutral position (no flexing). To assist in controlling ICP in clients with severe brain injury, the following are recommended: elevate the head of the bed as prescribed (gravity helps drain fluid), maintain head/neck in neutral alignment (no twisting or flexing), give sedation as ordered to prevent agitation, and avoid noxious stimuli (scatter procedures so that client does not become overtired).
Which of the following antiseizure medication has been found to be effective for post-stroke pain?
Lamotrigine aka Lamictal The antiseizure medication lamotrigine (Lamictal) has been found to be effective for post-stroke pain.
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?
Limited attention span and forgetfulness Damage to frontal lobe impairs learning capacity, memory, or other higher cortical intellectual functions. and may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation.
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?
Lung auscultation and measurement of vital capacity and tidal volume In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.
A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?
Monitoring is needed as rapid neurologic deterioration may occur. The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.
A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?
More than 200 mL/h For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus
The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis?
Muscle weakness and hyporeflexia of the lower extremities Guillain-Barre syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities. Fever, skin rash, cough, and ptosis are not signs/symptoms associated with Guillain-Barre.
A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?
Positive Brudzinski's sign A positive Brudzinski's sign is a common finding in the client with meningitis. When the client's neck is flexed, flexion of the knees and hips is produced. A positive Kernig's sign is usual with meningitis. The client will develop lethargy as the illness progresses, not increased intake or hyper-alertness.
The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following?
Positive Kernig's sign A positive Kernig's sign is a common finding in the client with meningitis. When the client is lying with the thigh flexed on the abdomen, the leg cannot be completly extended. A positive Brudzinski's sign is usual with meningitis. The Romberg sign would not be tested in this client. The client will develop lethargy as the illness progresses, not hyper-alertness.
The nurse is performing an initial assessment on a client who is admitted to rule out myasthenia gravis. Which of the following findings would the nurse expect to observe?
Ptosis and diplopia The initial manifestation of myasthenia gravis in two-thirds of clients involves the ocular muscles; diplopia and ptosis are common. Muscle weakness and hyporeflexia of the lower extremities are associated with Guillain-Barre syndrome. Facial distortion and pain are associated with Bell's palsy and tic douloureux.
A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for?
Rebound hypotension When the cause is removed and the symptoms abate, the blood pressure goes down. The antihyperstensive medication is still working. The nurse must watch for rebound hypotension. Rebound hypertension is not an issue. Spinal shock occurs right after the initial injury. The client is not at any more risk for a urinary tract infection after the episode than he was before.
A client has sustained a traumatic brain injury with involvement of the hypothalamus. The health care team is concerned about the complication of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?
Record intake and output. A record of intake and output is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. Excessive output will alert the nurse to possible fluid imbalance early in the process.
A patient diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this patient most likely has?
Relapsing-remitting (RR) Approximately 85% of patients with MS have a relapsing-remitting (RR) course. With each relapse, recovery is usually complete; however, residual deficits may occur and accumulate over time, contributing to functional decline.
Regarding a CVA. One concern the APN addresses is a potential for falls. What would be most important for the APN to include in teaching of the client and family related to this concern?
Remove throw rugs and electrical cords from home environment. Also, clutter, and electrical cords from the client's home environment to reduce the potential for falls.
The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily?
Respiratory Because of its possible rapid progression and neuromuscular respiratory failure, Guillain-Barre syndrome is a medical emergency. After baseline values are identified, assessment of changes in muscle strength and respiratory function alert the team to the physical and respiratory needs of the client. The other three choices may become problem areas later, but respiratory issues are always a priority.
A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?
Restricting fluid intake and hydration Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurological infection should be given tracheal suctioning and hyperoxygenation only when respiratory distress develops.
A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?
Restricting fluid intake and hydration Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurological infection should be given tracheal suctioning and hyperoxygenation only when respiratory distress develops.
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?
Seizure was 1 minute in duration including tonic-clonic activity. Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?
Spasticity Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.
A college student is admitted to the emergency room to be evaluated for aseptic meningitis. The nurse knows that the most serious infecting organism (34% mortality rate) is:
Streptococcus pneumoniae Septic meningitis is caused by bacteria; commonly Streptococcus pneumoniae and Neisseria meningitidis. For patients over 50, additional causative organisms include Listeria monocytogenes and aerobic gram-negative bacilli. Haemophilus influenzae is still a concern for those not immunized for H. influenzae.
A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?
Suction machine with catheters MS weakens the respiratory muscles and impairs swallowing, putting the client at risk for aspiration. To ensure a patent oral airway, the nurse should keep a suction machine and suction catheters at the bedside. A sphygmomanometer is no more important for this client than for any other. A padded tongue blade is an appropriate seizure precaution but shouldn't be used in this client because its large size could cause oral airway obstruction. A nasal cannula and oxygen would be ineffective to ensure adequate oxygen delivery; this client requires a mechanical ventilator.
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels
T6 Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.
Which of the following is not a manifestation of Cushing's Triad? a. bradycardia b. tachycardia c. hypertension d. bradypnea
Tachycardia Cushing's triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.
A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?
Take daily weights. A record of daily weights is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. A weight loss will alert the nurse to possible fluid imbalance early in the process.
The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?
Temperature increase from 98.0°F to 99.6°F Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?
Tensilon test Edrophonium chloride (Tensilon) is an acetylcholinesterase inhibitor that stops the breakdown of acetylcholine. The drug is used because it has a rapid onset of 30 seconds and a short duration of 5 minutes. Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis. The presence of acetylcholine receptor antibodies is identified in serum. Repetitive nerve stimulation demonstrates a decrease in successive action potentials. The thymus gland may be enlarged in MG, and a T scan of the mediastinum is performed to detect thymoma or hyperplasia of the thymus.
Which of the following is accurate regarding a hemorrhagic stroke?
The Main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months;
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
The client will remain free of injury if a seizure does occur. All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.
A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose?
The muscles will become fatigued and the patient will not be able to chew food or swallow pills Maintenance of stable blood levels of anticholinesterase medications, such as pyridostigmine (Mestinon), is imperative to stabilize muscle strength. Therefore, the anticholinesterase medications must be administered on time. Any delay in administration of medications may exacerbate muscle weakness and make it impossible for the patient to take medications orally.
A patient with impaired swallowing should be helped to eat food with texture. Sit patient upright , flex patient's chin toward the chest, feed slowly & promote easy swallowing to reduce risk of aspiration or airway obstruction.
The patient should be allowed to rest before meals because fatigue may interfere with coordination and following instructions. Liquids should be offered frequently but in small quantities.
What is the treatment window for thrombolytic therapy (TPA)
Three hours. Rapid diagnosis of stroke and initiation of thrombolytic therapy within 3 hours for ischemic stroke leads to decrease size of the stroke and improvement in functional outcome after 3 months.
A client is has right-sided weakness. Within 6 hours of being admitted, the neurologic deficits has resolved and the client was back to their presymptomatic state. Tthe probable cause of the neurologic deficit was what?
Transient ischemic attack A transient ischemic attack TIA is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow.
A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate?
Treatment with antimicrobial prophylaxis as soon as possible People in close contact with clients who have meningococcal meningitis should be treated with antimicrobial chemoprophylaxis, ideally within 24 hours after exposure.
What is the chief cause of intracerebral hemorrhage (ICH)?
Uncontrolled hypertension. Primary intracerebral hemorrhage (ICH) from a spontaneous rupture of small arteries or arterioles accounts for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension.
A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure?
Unequal response In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated.
A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find? a) Vision changes b) Flaccid muscles c) Tremors at rest d) Absent deep tendon reflexes
Vision changes Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of MS. Deep tendon reflexes may be increased or hyperactive — not absent. Babinski's reflex may be positive. Tremors at rest aren't characteristic of MS; however, intentional tremors (those occurring with purposeful voluntary movement) are common in clients with MS. Affected muscles are spastic, rather than flaccid.
What is the primary initial symptoms of an ischemic stroke?
Weakness on one side of the body and difficulty with speech
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?
Widened pulse pressure Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations become rapid, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.
A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?
Within 24 hours after exposure People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy should be started within 24 hours after exposure because a delay in the initiation of therapy limits the effectiveness of the prophylaxis.
What is associated with hemorrhagic strokes in young people a. Arteriovenous malformations b. hypertension
a
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:
a positive edrophonium (Tensilon) test. A positive edrophonium test confirms the diagnosis of myasthenia gravis. After edrophonium administration, most clients with myasthenia gravis show markedly improved muscle tone. Kernig's sign and Brudzinski's sign indicate meningitis. The sweat chloride test is used to confirm cystic fibrosis.
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:
carefully move the client to a flat surface and turn him on his side. When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat nonelevated surface and then position him on his side to ensure that he doesn't aspirate and to protect him from injury. These steps help reduce the risk of injury from falling or hitting surrounding objects and help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of the mouth.
While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivate nurses to offer the best care possible is preventing:
complications. Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function.
Which of the following is a contraindication for the administration of tissue plasminogen activator aka t-PA.
hemorrhagic stroke
To meet the sensory needs of a client with viral meningitis, the nurse should:
minimize exposure to bright lights and noise. Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli. Physical activity may worsen symptoms; therefore, physical activity should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:
raccoon's eyes and Battle sign. A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. Nuchal rigidity and Kernig's sign are associated with meningitis. Motor loss in the legs that exceeds that in the arms suggests central cord syndrome. Pupillary changes are common in skull fractures with associated meningeal artery bleeding and uncal herniation.
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in an air-conditioned room. Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.